Access and Discontinuity of Care at an Outpatient Mental Health Service for Older People in South Western Nigeria.

We examined frequency and reasons for dropout from follow-up care at an outpatient mental health service for older people in South-Western Nigeria. This was a cross-sectional study. Administrative reviews of 201 case records of clinic attendees who received a psychiatric diagnosis that required follow-up consultations were conducted. Records were those of patients seen between January 2015 and December 2017. Chart extraction was followed by Key Informant Interview (KII) to explore the reasons for drop out and partial non-attendance. We identified 37(18.4%) regular clinic attendees, as well as 147(73.1%) and 17(8.5%) dropout and partially attending patients, respectively. Approximately 45.6% of the dropouts occurred after the first consultation. In KII, distance from the hospital, long waiting times and financial constraints were the common reasons for dropout. The findings of this study should inform the development of strategies to improve access to mental health services in Nigeria and other low- and middle-income countries.

The Epidemiology of Suicide and Suicidal Behaviour across the Lifespan in Nigeria: A Systematic Review of the Literature.

BACKGROUND/PURPOSE: Suicidal behaviour is a global public health issue affecting all ages, gender, and regions of the world. This systematic review sought to synthesize the available evidence on the prevalence and risk factors for suicide and suicidal behaviour across the lifespan in Nigeria. DATA SOURCE: The databases of PubMed, Embase, Medline, PsychInfo, Google Scholar and African Journals OnLine (AJOL). STUDY SELECTION: Literature on suicidal behaviour and suicide from Nigeria published between 2000 and 2019. DATA EXTRACTION: Data were extracted independently by two authors using a fixed template. RESULTS: The search identified 431 articles; 23 were eligible for inclusion. The 12-month prevalence of suicide ideation among adolescents was between 6.1-22.9% and 3-12.5% for attempts; identified risk factors were sexual abuse, family dysfunction and food insecurity. For the adult population, lifetime rates of suicidal ideation, plan and attempt were 3.2%, 1.0% and 0.7% respectively; risk factors included age (peak in the third decade of life), childhood adverse experiences and the presence of mood disorders. In the elderly the rates were 4.0% for ideation, 0.7% for plan and 0.2% for attempt. Risk factors identified in the elderly were being single (separation or widowhood) and rural residence. Suicides accounted for 0.3- 1.6% of autopsies performed by the coroners and constituted the least common cause of death. Suicides were more common in males and peaked in the third decade of life. CONCLUSION: Suicide and suicidal behaviour in the Nigerian population seem to peak in young adult life suggesting that suicide prevention initiatives should target late adolescence.

CONTEXTE/BUT: Le comportement suicidaire est un problème mondial de santé publique qui touche tous les âges, tous les sexes et toutes les régions du monde. Cet examen systématique visait à synthétiser les données probantes disponibles sur la prévalence et les facteurs de risque de suicide et de comportement suicidaire tout au long de la vie au Nigéria. SOURCE DE DONNEES: Les bases de données de PubMed, Embase, Medline, PsychInfo, Google Scholar et African Journals OnLine (AJOL). SELECTION DE L'ETUDE: Publication de la littérature sur les comportements suicidaires et le suicide au Nigéria entre 2000 et 2019. EXTRACTION DE DONNEES: Les données ont été extraites indépendamment par deux auteurs à l'aide d'un modèle fixe. RESULTATS: La recherche a permis d'identifier 431 articles; 23 étaient admissibles à l'inclusion. La prévalence sur 12 mois de l'idée de suicide chez les adolescents se situe entre 6,1 et 22,9 % et 3 à 12,5 % pour les tentatives; les facteurs de risque identifiés étaient la violence sexuelle, le dysfonctionnement familial et l'insécurité alimentaire. Pour la population adulte, les taux à vie d'idées, de planifier et de tenter suicidaires étaient de 3,2 %, 1,0 % et 0,7 % respectivement; les facteurs de risque comprenaient l'âge (sommet au cours de la troisième décennie de la vie), les expériences indésirables de l'enfance et la présence de troubles de l'humeur. Chez les personnes âgées, les taux étaient de 4,0 % pour l'idée, de 0,7 % pour le régime et de 0,2 % pour les tentatives. Les facteurs de risque identifiés chez les personnes âgées étaient état matrimonial célibataire (séparation ou veuvage) et la résidence rurale. Les suicides représentaient de 0,3 à 1,6 % des autopsies effectuées par les coroners et constituaient la cause de décès la moins fréquente. Les suicides étaient plus fréquents chez les hommes et ont atteint un sommet au cours de la troisième décennie de leur vie. CONCLUSION: Le suicide et les comportements suicidaires dans la population Nigériane semblent culminer chez les jeunes adultes, ce qui suggère que les initiatives de prévention du suicide devraient cibler la fin de l'adolescence. Mots-clés: Le suicide, comportements suicidaires, Les facteurs de risque, autopsies du coroner, la vie.

The associations of earlier trauma exposures and history of mental disorders with PTSD after subsequent traumas.

Although earlier trauma exposure is known to predict posttraumatic stress disorder (PTSD) after subsequent traumas, it is unclear whether this association is limited to cases where the earlier trauma led to PTSD. Resolution of this uncertainty has important implications for research on pretrauma vulnerability to PTSD. We examined this issue in the World Health Organization (WHO) World Mental Health (WMH) Surveys with 34 676 respondents who reported lifetime trauma exposure. One lifetime trauma was selected randomly for each respondent. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) PTSD due to that trauma was assessed. We reported in a previous paper that four earlier traumas involving interpersonal violence significantly predicted PTSD after subsequent random traumas (odds ratio (OR)=1.3-2.5). We also assessed 14 lifetime DSM-IV mood, anxiety, disruptive behavior and substance disorders before random traumas. We show in the current report that only prior anxiety disorders significantly predicted PTSD in a multivariate model (OR=1.5-4.3) and that these disorders interacted significantly with three of the earlier traumas (witnessing atrocities, physical violence victimization and rape). History of witnessing atrocities significantly predicted PTSD after subsequent random traumas only among respondents with prior PTSD (OR=5.6). Histories of physical violence victimization (OR=1.5) and rape after age 17 years (OR=17.6) significantly predicted only among respondents with no history of prior anxiety disorders. Although only preliminary due to reliance on retrospective reports, these results suggest that history of anxiety disorders and history of a limited number of earlier traumas might usefully be targeted in future prospective studies as distinct foci of research on individual differences in vulnerability to PTSD after subsequent traumas.

Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

Recovery from DSM-IV post-traumatic stress disorder in the WHO World Mental Health surveys.

BACKGROUND: Research on post-traumatic stress disorder (PTSD) course finds a substantial proportion of cases remit within 6 months, a majority within 2 years, and a substantial minority persists for many years. Results are inconsistent about pre-trauma predictors. METHODS: The WHO World Mental Health surveys assessed lifetime DSM-IV PTSD presence-course after one randomly-selected trauma, allowing retrospective estimates of PTSD duration. Prior traumas, childhood adversities (CAs), and other lifetime DSM-IV mental disorders were examined as predictors using discrete-time person-month survival analysis among the 1575 respondents with lifetime PTSD. RESULTS: 20%, 27%, and 50% of cases recovered within 3, 6, and 24 months and 77% within 10 years (the longest duration allowing stable estimates). Time-related recall bias was found largely for recoveries after 24 months. Recovery was weakly related to most trauma types other than very low [odds-ratio (OR) 0.2-0.3] early-recovery (within 24 months) associated with purposefully injuring/torturing/killing and witnessing atrocities and very low later-recovery (25+ months) associated with being kidnapped. The significant ORs for prior traumas, CAs, and mental disorders were generally inconsistent between early- and later-recovery models. Cross-validated versions of final models nonetheless discriminated significantly between the 50% of respondents with highest and lowest predicted probabilities of both early-recovery (66-55% v. 43%) and later-recovery (75-68% v. 39%). CONCLUSIONS: We found PTSD recovery trajectories similar to those in previous studies. The weak associations of pre-trauma factors with recovery, also consistent with previous studies, presumably are due to stronger influences of post-trauma factors.

The perceived effectiveness of traditional and faith healing in the treatment of mental illness: a systematic review of qualitative studies.

PURPOSE: This work complements a quantitative review by Nortje et al. (Lancet Psychiatry 3(2):154-170, 2016) by exploring the qualitative literature in regard to the perceived effectiveness of traditional and faith healing of mental disorders. METHOD: Qualitative studies focusing specifically on traditional and/or faith healing practices for mental illness were retrieved from eight databases. Data were extracted  into basic coding sheets to facilitate the assessment of the quality of eligible papers using the COREQ. RESULTS: Sixteen articles met the inclusion criteria. Despite methodological limitations, there was evidence from the papers that stakeholders perceived traditional and/or faith healing to be effective in treating mental illness, especially when used in combination with biomedical treatment. CONCLUSION: Patients will continue to seek treatment from traditional and/or faith healers for mental illness if they perceive it to be effective regardless of alternative biomedical evidence. This provides opportunities for collaboration to address resource scarcity in low to middle income countries.

The cross-national epidemiology of specific phobia in the World Mental Health Surveys.

BACKGROUND: Although specific phobia is highly prevalent, associated with impairment, and an important risk factor for the development of other mental disorders, cross-national epidemiological data are scarce, especially from low- and middle-income countries. This paper presents epidemiological data from 22 low-, lower-middle-, upper-middle- and high-income countries. METHOD: Data came from 25 representative population-based surveys conducted in 22 countries (2001-2011) as part of the World Health Organization World Mental Health Surveys initiative (n = 124 902). The presence of specific phobia as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition was evaluated using the World Health Organization Composite International Diagnostic Interview. RESULTS: The cross-national lifetime and 12-month prevalence rates of specific phobia were, respectively, 7.4% and 5.5%, being higher in females (9.8 and 7.7%) than in males (4.9% and 3.3%) and higher in high- and higher-middle-income countries than in low-/lower-middle-income countries. The median age of onset was young (8 years). Of the 12-month patients, 18.7% reported severe role impairment (13.3-21.9% across income groups) and 23.1% reported any treatment (9.6-30.1% across income groups). Lifetime co-morbidity was observed in 60.5% of those with lifetime specific phobia, with the onset of specific phobia preceding the other disorder in most cases (72.6%). Interestingly, rates of impairment, treatment use and co-morbidity increased with the number of fear subtypes. CONCLUSIONS: Specific phobia is common and associated with impairment in a considerable percentage of cases. Importantly, specific phobia often precedes the onset of other mental disorders, making it a possible early-life indicator of psychopathology vulnerability.

The association between childhood adversities and subsequent first onset of psychotic experiences: a cross-national analysis of 23 998 respondents from 17 countries.

BACKGROUND: Although there is robust evidence linking childhood adversities (CAs) and an increased risk for psychotic experiences (PEs), little is known about whether these associations vary across the life-course and whether mental disorders that emerge prior to PEs explain these associations. METHOD: We assessed CAs, PEs and DSM-IV mental disorders in 23 998 adults in the WHO World Mental Health Surveys. Discrete-time survival analysis was used to investigate the associations between CAs and PEs, and the influence of mental disorders on these associations using multivariate logistic models. RESULTS: Exposure to CAs was common, and those who experienced any CAs had increased odds of later PEs [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.9-2.6]. CAs reflecting maladaptive family functioning (MFF), including abuse, neglect, and parent maladjustment, exhibited the strongest associations with PE onset in all life-course stages. Sexual abuse exhibited a strong association with PE onset during childhood (OR 8.5, 95% CI 3.6-20.2), whereas Other CA types were associated with PE onset in adolescence. Associations of other CAs with PEs disappeared in adolescence after adjustment for prior-onset mental disorders. The population attributable risk proportion (PARP) for PEs associated with all CAs was 31% (24% for MFF). CONCLUSIONS: Exposure to CAs is associated with PE onset throughout the life-course, although sexual abuse is most strongly associated with childhood-onset PEs. The presence of mental disorders prior to the onset of PEs does not fully explain these associations. The large PARPs suggest that preventing CAs could lead to a meaningful reduction in PEs in the population.

Posttraumatic stress disorder in the World Mental Health Surveys.

BACKGROUND: Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking. METHODS: Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics. RESULTS: The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed. CONCLUSIONS: PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

The association between psychotic experiences and disability: results from the WHO World Mental Health Surveys.

OBJECTIVE: While psychotic experiences (PEs) are known to be associated with a range of mental and general medical disorders, little is known about the association between PEs and measures of disability. We aimed to investigate this question using the World Mental Health surveys. METHOD: Lifetime occurrences of six types of PEs were assessed along with 21 mental disorders and 14 general medical conditions. Disability was assessed with a modified version of the WHO Disability Assessment Schedule. Descriptive statistics and logistic regression models were used to investigate the association between PEs and high disability scores (top quartile) with various adjustments. RESULTS: Respondents with PEs were more likely to have top quartile scores on global disability than respondents without PEs (19.1% vs. 7.5%; χ2  = 190.1, P < 0.001) as well as greater likelihood of cognitive, social, and role impairment. Relationships persisted in each adjusted model. A significant dose-response relationship was also found for the PE type measures with most of these outcomes. CONCLUSIONS: Psychotic experiences are associated with disability measures with a dose-response relationship. These results are consistent with the view that PEs are associated with disability regardless of the presence of comorbid mental or general medical disorders.

The incidence of psychoses in diverse settings, INTREPID (2): a feasibility study in India, Nigeria, and Trinidad.

BACKGROUND: There are striking global inequities in our knowledge of the incidence, aetiology, and outcome of psychotic disorders. For example, only around 10% of research on incidence of psychotic disorders originates in low- and middle-income countries. We established INTREPID I to develop, implement, and evaluate, in sites in India (Chengalpet), Nigeria (Ibadan), and Trinidad (Tunapuna-Piarco), methods for identifying and recruiting untreated cases of psychosis, as a basis for investigating incidence and, subsequently, risk factors, phenomenology, and outcome. In this paper, we compare case characteristics and incidence rates across the sites. METHOD: In each site, to identify untreated cases of psychoses in defined catchment areas, we established case detection systems comprising mental health services, traditional and spiritual healers, and key informants. RESULTS: Rates of all untreated psychoses were 45.9 (per 1 00 000 person-years) in Chengalpet, 31.2 in Ibadan, and 36.9 in Tunapuna-Piarco. Duration of psychosis prior to detection was substantially longer in Chengalpet (median 232 weeks) than in Ibadan (median 13 weeks) and Tunapuna-Piarco (median 38 weeks). When analyses were restricted to cases with a short duration (i.e. onset within preceding 2 years) only, rates were 15.5 in Chengalpet, 29.1 in Ibadan, and 26.5 in Tunapuna-Piarco. Further, there was evidence of age and sex differences across sites, with an older average age of onset in Chengalpet and higher rates among women in Ibadan. CONCLUSION: Our findings suggest there may be differences in rates of psychoses and in the clinical and demographic profiles of cases across economically and socially distinct settings.

The cross-national epidemiology of DSM-IV intermittent explosive disorder.

BACKGROUND: This is the first cross-national study of intermittent explosive disorder (IED). METHOD: A total of 17 face-to-face cross-sectional household surveys of adults were conducted in 16 countries (n = 88 063) as part of the World Mental Health Surveys initiative. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) assessed DSM-IV IED, using a conservative definition. RESULTS: Lifetime prevalence of IED ranged across countries from 0.1 to 2.7% with a weighted average of 0.8%; 0.4 and 0.3% met criteria for 12-month and 30-day prevalence, respectively. Sociodemographic correlates of lifetime risk of IED were being male, young, unemployed, divorced or separated, and having less education. The median age of onset of IED was 17 years with an interquartile range across countries of 13-23 years. The vast majority (81.7%) of those with lifetime IED met criteria for at least one other lifetime disorder; co-morbidity was highest with alcohol abuse and depression. Of those with 12-month IED, 39% reported severe impairment in at least one domain, most commonly social or relationship functioning. Prior traumatic experiences involving physical (non-combat) or sexual violence were associated with increased risk of IED onset. CONCLUSIONS: Conservatively defined, IED is a low prevalence disorder but this belies the true societal costs of IED in terms of the effects of explosive anger attacks on families and relationships. IED is more common among males, the young, the socially disadvantaged and among those with prior exposure to violence, especially in childhood.

Mental disorders among college students in the World Health Organization World Mental Health Surveys.

BACKGROUND: Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years. METHOD: The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1572) and non-students in the same age range (18-22 years; n = 4178), including non-students who recently left college without graduating (n = 702) based on surveys in 21 countries (four low/lower-middle income, five upper-middle-income, one lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioral and substance disorders were assessed with the Composite International Diagnostic Interview (CIDI). RESULTS: One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders; 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders. CONCLUSIONS: Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.

The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium.

BACKGROUND: Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs. METHOD: General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure. RESULTS: Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types - witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury - accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events. CONCLUSIONS: Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.

Sociodemographic correlates of continuing tobacco use - a descriptive report from the Nigerian Survey of Mental Health and Wellbeing.

OBJECTIVE: To investigate whether sociodemographic factors were associated with continuing tobacco use in a nationwide Nigerian sample. METHOD: The World Mental Health Survey Schedule was used to interview 6752 Community dwelling participants 18 years and over, selected in a complex multistage sampling from the six geopolitical zones of Nigeria. Ever and current smokers were identified with their sociodemographic characteristics. RESULTS: About 17% (1137/6752) of the participants were ever smokers, 24.8% of whom were current smokers. Participants who completed primary school, had some College education, were never married, or students were more likely to continue using smoke once they commenced its use. Being in the older age group or having had graduate college education was associated with much less likelihood of continuing to use tobacco among ever smokers. CONCLUSION: In general, tobacco smoking rate in Nigeria is lower compared to most developed countries. Younger participants, having some education, those who were never married were more likely to continue tobacco smoking. Determinants of factors associated with continuing tobacco use should be adequately investigated to permit appropriate interventions.

Lifetime and 7-day alcohol consumption in the elderly, prevalence and correlates: Reports from the Ibadan Study of Aging.

INTRODUCTION: There is a dearth of information on alcohol consumption in the elderly in Africa. The aim of the study was to determine the prevalence of lifetime and 7 day alcohol consumption in a community sample of elderly Nigerians and the association of 7 day excessive alcohol consumption to several common health conditions. METHODS: Face-to-face interviews were carried out among 2,149 elderly persons aged 65 years and older, selected through a multistage stratified sampling method of households in the Yoruba-speaking areas of Nigeria (22% of Nigerian population). Using a daily inventory of drinking, lifetime and 7-day alcohol consumption estimates were derived. Excessive alcohol consumption was defined as use of more than 1 unit/day at a sitting or more than 7 units/week. Major depressive disorder was assessed with the WHO Composite International Diagnostic Interview; chronic general medical conditions were assessed by self reports. RESULTS: Majority (54.8%) of the respondents were lifetime abstainers. Past-week alcohol use was reported by 12.0% of men and 3.6% of women. Drinking rates declined with increasing age in both sexes (p < 0.05). Past week excessive alcohol consumption was less likely among persons residing in rural areas, OR = 0.41 95% CI (0.17-0.99) but more likely to be associated with chronic backache or neck pain OR = 2.04, 95% Cl, (1.0-4.59 and cognitive impairment OR=4.2, 95% CI, (1.21-15.1). CONCLUSION: Excessive consumption is relatively common among elderly males. Alcohol consumption in the elderly is associated with chronic pain, cognitive impairment and living in urban areas.

Barriers to mental health treatment: results from the WHO World Mental Health surveys.

BACKGROUND: To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders. METHOD: Data were from the World Health Organization (WHO) World Mental Health (WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 63,678) and analyzed at different levels of clinical severity. RESULTS: Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders). CONCLUSIONS: Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.

The effects of co-morbidity in defining major depression subtypes associated with long-term course and severity.

BACKGROUND: Although variation in the long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about co-morbid conditions. The current report presents results on this question. METHOD: Data came from 8261 respondents with lifetime DSM-IV MDD in the World Health Organization (WHO) World Mental Health (WMH) Surveys. Outcomes included four retrospectively reported measures of persistence/severity of course (years in episode; years in chronic episodes; hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously detected subtypes with information about prior co-morbidity to predict these outcomes. RESULTS: Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found three clusters with consistently high, intermediate or low values. The high-risk cluster (32.4% of cases) accounted for 56.6-72.9% of high persistence, high chronicity, hospitalization and disability. This high-risk cluster had both higher sensitivity and likelihood ratio positive (LR+; relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of co-morbidity as predictors. CONCLUSIONS: Although the results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence/severity, replication with prospective data is needed to confirm this preliminary conclusion.

Embarrassment when illness strikes a close relative: a World Mental Health Survey Consortium Multi-Site Study.

BACKGROUND: In this global study we sought to estimate the degree to which a family member might feel embarrassed when a close relative is suffering from an alcohol, drug, or mental health condition (ADMC) versus a general medical condition (GMC). To date, most studies have considered embarrassment and stigma in society and internalized by the afflicted individual but have not assessed family embarrassment in a large-scale study. METHOD: In 16 sites of the World Mental Health Surveys (WMHS), standardized assessments were completed including items on family embarrassment. Site matching was used to constrain local socially shared determinants of stigma-related feelings, enabling a conditional logistic regression model that estimates the embarrassment close relatives may hold in relation to family members affected by an ADMC, a GMC, or both conditions. RESULTS: There was a statistically robust association such that subgroups with an ADMC-affected relative were more likely to feel embarrassed compared to subgroups with a relative affected by a GMC (p<0.001), even with covariate adjustments for age and sex. CONCLUSIONS: . The pattern of evidence from this research is consistent with conceptual models for interventions that target individual- and family-level stigma-related feelings of embarrassment as possible obstacles to effective early intervention and treatment for an ADMC. Macro-level interventions are under way but micro-level interventions may also be required among family members, along with care for each person with an ADMC.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys.

BACKGROUND: Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition. RESULTS: Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings. CONCLUSIONS: Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.